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This form is interactive — complete electronically and print Page 1 of 7 Criminal Background Check Form EM 150 Created: October 23, 2012 Updated: November 8, 2018 Document can be printed double-sided to save paper. Draft 12 The University of Texas at Austin has an obligation to provide a safe environment for all members of the UT Austin community and to protect the property of UT Austin. For these reasons, all job applicants must provide and certify any requirement to register as a sex offender and their complete adult criminal conviction record. This includes any conviction and/or deferred adjudication where the final disposition is still pending (i.e. the original charge has not been judicially dismissed) from the age of 17 until now. Before an applicant is referred to or hired for a specific job vacancy, the severity, time since conviction, and direct job relatedness of his or her conviction(s) are compared to the functions of the vacant position. Based on that review, an applicant may not be referred, or hired. However, a criminal conviction does not necessarily disqualify an individual from being hired. Notice Concerning Your Information The Texas Public Information Act, with a few exceptions, gives you the right to be informed about the information that The University of Texas at Austin collects about you. It also gives you the right to request a copy of that information; and to have the University correct any of that information that is wrong. You may request to receive and review any of that information, or request corrections to it, by contacting the University's Public Information Officer, Office of Financial Affairs, PO Box 8179, Austin, Texas, 78713, e-mail: [email protected]. Disclosure of Social Security numbers (SSN) is requested from you in order for The University of Texas at Austin to complete a background check. No statute or other authority requires that you disclose your SSN for that purpose. Failure to provide your SSN, however, may result in dismissal or ineligibility to be hired. Further disclosure of your SSN is governed by the Public Information Act (Chapter 552 of the Texas Government Code) and other applicable law. THIS SECTION TO BE COMPLETED BY AN APPLICANT OR EMPLOYEE FROM WHOM A CRIMINAL BACKGROUND CHECK IS REQUIRED Clearly print all information. Provide all information requested. Falsification of any information on this form will void your application for employment and any actions based on it. The information on this form, including any attachments, is property of The University of Texas at Austin. Return this document to your department, not HRS. Summary of Rights and Texas Summary of Rights provided at the end of the document. Last name First name Middle name Maiden/Alias Current Street Address (No P.O. Boxes) City State Zip code Previous Street Address (No P.O. Boxes) City State Zip code E-mail address Social Security # Driver's License/ID # and State Gender Male Female Date of birth UT EID Are you required to register as a sex offender in Texas or any other state? Yes No Do you have any criminal convictions since age 17 or older or any deferred adjudications where the final disposition is still pending (i.e. the original charge has not been dismissed)? Yes No Zip code State City Previous Street Address (No P.O. Boxes) Please provide your address history for the past 7 years. If you are under 25 years of age, you only need to provide addresses since age 17. Begin Date End Date End Date Begin Date End Date Begin Date Phone # If yes, list year(s) of conviction(s) and nature of offense(s) and penalty(ies). If additional space is needed, attach a separate sheet. Date Location of Conviction (city/state) Nature of Conviction (no abbreviations) Level of Conviction (misdemeanor, felony, pending deferred adjudication) Human Resources · 1616 Guadalupe Street, STOP J5600 · Austin, Texas 78701 [email protected] · hr.utexas.edu · phone 512-471-4772 · fax 512-232-3524
